=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134908981
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARDIO AND VASCULAR IMAGING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2023
-----------------------------------------------------
Last Update Date | 09/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1028 S KIRKWOOD RD
-----------------------------------------------------
City | KIRKWOOD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63122-7222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-398-3975
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1746 TIMBER RIDGE ESTATES DR
-----------------------------------------------------
City | WILDWOOD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63011-1976
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-398-3975
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. KIRK CARLILE
-----------------------------------------------------
Credential | RDCS, RVS
-----------------------------------------------------
Telephone | 314-398-3975
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------